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Fraud

Last Modified: 8/8/2016 9:50:55 AM

Article: KB00151

Health Care Fraud and Abuse

Health care fraud occurs when a person or business intentionally misrepresents facts to
receive reimbursement for health care services or supplies.
It’s a criminal offense under state and federal laws and can result in hefty fines,
loss of health care coverage, and/or criminal penalties — including jail time.
It also results in higher costs for all HMSA members.

Using another person’s HMSA membership card or subscriber number, or allowing someone to use yours.

Changing claim and billing documents.

Making false statements on a health plan application or adding someone who isn’t eligible for coverage to a health plan.

Withholding information about additional health care coverage.

The price of fraud and abuse

Everyone pays the price for health care fraud through higher health plan dues and out-of-pocket costs.
It also results in reduced health plan benefits and coverage to make up for higher costs.

Health care fraud costs an estimated $68 billion to $226 billion annually.
According to the Blue Cross and Blue Shield Association, each family in the U.S. pays more than $800 extra
in health care costs every year because of health care fraud.

Penalties for fraud and abuse

Your health plan coverage will be canceled immediately if you are fraudulently enrolled due to
misrepresenting or concealing facts on your enrollment form.
You must reimburse HMSA for all claims HMSA paid on your behalf. HMSA also has the right to initiate a
civil action to recover losses based on fraud, concealment, or misrepresentation.

HMSA’s anti-fraud efforts

HMSA takes all types of health care fraud very seriously.
Our Benefits Integrity staff works to prevent fraud and recover money resulting from fraud.
HMSA’s anti-fraud efforts save our members about $8 million a year.
Also, the Affordable Care Act passed last year calls for stricter enforcement and penalties to combat enrollment fraud.

Prevent health plan enrollment fraud

You can help prevent enrollment fraud.
Contact your employer or health plan if you need to remove a dependent from your health plan who is
no longer eligible for coverage. For example:

If you get a divorce, your former spouse may not be eligible to remain on your health plan.

A child who is no longer considered your legal dependent may not be eligible to remain on your health plan.